Anupama Kaul

Real-time ultrasound-guided percutaneous renal biopsy with needle guide by nephrologists decreases post-biopsy complications

Background Percutaneous renal biopsy (PRB) can result in serious complications. The study is aimed to compare the biopsy yield and complications rate of the real-time ultrasonagram (USG)-guided PRB and needle tracking with and without needle guide in two different study periods. Methods We compared the yield and complications of 2138 kidney biopsies performed in two different periods, 1510 biopsies during the first period from April 2004–December 2010 and 628 biopsies during second period from January 2011–March 2013. All biopsies in both periods were performed by nephrologists. Radiologists provided the real-time image without needle guide during the first period while nephrologists performed both imaging and biopsy with needle guide during the second period. Results Of all the 2138 patients, 226 (10.5%) patients developed 118 minor and 108 major complications. Only 13 (2.1%) major complications occurred in the second period and 95 (6.7%) in the first period (P < 0.001). The relative risk of developing a major complication without guide was 3.04 times greater than that of the biopsies performed with use of the guide. The mean number of glomeruli per biopsy obtained during the second period (17.98 ± 6.75) was significantly greater than that of the first period (14.14 ± 6.01) (P = 0.004). The number of passes to acquire adequate tissue (P = 0.001) and percentage of cortex on biopsy (P = 0.001) were also significantly better in the second period. The optimal observation period post biopsy is 24 h. Conclusions Real-time USG imaging supported by needle guide device is associated with better biopsy yield and fewer complications.

Effect of Body Mass Index on Outcomes of Peritoneal Dialysis Patients in India

♦ Objectives: We studied the effect of body mass index (BMI) at peritoneal dialysis (PD) initiation on patient and technique survival and on peritonitis during follow-up. ♦ Methods: We followed 328 incident patients on PD (176 with diabetes; 242 men; mean age: 52.6 ± 12.6 years; mean BMI: 21.9 ± 3.8 kg/m2) for 20.0 ± 14.3 months. Patients were categorized into four BMI groups: obese, ≥25 kg/m2; overweight, 23 - 24.9 kg/m2; normal, 18.5 - 22.9 kg/m2 (reference category); and underweight, <18.5 kg/m2. The outcomes of interest were compared between the groups. ♦ Results: Of the 328 patients, 47 (14.3%) were underweight, 171 (52.1%) were normal weight, 53 (16.2%) were overweight, and 57 (17.4%) were obese at commencement of PD therapy. The crude hazard ratio (HR) for mortality (p = 0.004) and the HR adjusted for age, subjective global assessment, comorbidities, albumin, diabetes, and residual glomerular filtration rate (p = 0.02) were both significantly greater in the underweight group than in the normal-weight group. In comparison with the reference category, the HR for mortality was significantly greater for underweight PD patients with diabetes [2.7; 95% confidence interval (CI): 1.5 to 5.0; p = 0.002], but similar for all BMI categories of nondiabetic PD patients. Median patient survival was statistically inferior in underweight patients than in patients having a normal BMI. Median patient survival in underweight, normal, overweight, and obese patients was, respectively, 26 patient-months (95% CI: 20.9 to 31.0 patient-months), 50 patient-months (95% CI: 33.6 to 66.4 patient-months), 57.7 patient-months (95% CI: 33.2 to 82.2 patient-months), and 49 patient-months (95% CI: 18.4 to 79.6 patient-months; p = 0.015). Death-censored technique survival was statistically similar in all BMI categories. In comparison with the reference category, the odds ratio for peritonitis occurrence was 1.8 (95% CI: 0.9 to 3.4; p = 0.086) for underweight patients; 1.7 (95% CI: 0.9 to 3.2; p = 0.091) for overweight patients; and 3.4 (95% CI: 1.8 to 6.4; p < 0.001) for obese patients. ♦ Conclusions: In our PD patients, mean BMI was within the normal range. The HR for mortality was significantly greater for underweight diabetic PD patients than for patients in the reference category. Death-censored technique survival was similar in all BMI categories. Obese patients had a greater risk of peritonitis.

Confounding Effect of Comorbidities and Malnutrition on Survival of Peritoneal Dialysis Patients

BACKGROUND AND OBJECTIVES Malnutrition and comorbid diseases are strong predictors of mortality in patients on continuous ambulatory peritoneal dialysis (CAPD). We undertook this study to analyze the confounding impact of comorbidities and malnutrition on the survival of CAPD patients. METHODS In this prospective, observational study, 342 CAPD patients (179 diabetics, 250 male, aged 51.5 ± 14 years) were followed for 21.62 ± 14.38 S.D. patient-months. Based on nutritional status and comorbidities, patients were categorized into four groups: (1), normal nutrition without comorbidities (n = 61, 17.8%); (2), normal nutrition with comorbidities (n = 26, 7.6%); (3), malnutrition with comorbidities (n = 160, 46.8%); and (4), malnutrition without comorbidities (n = 95, 27.8%). The risk ratios of mortality and predictors of survival were analyzed in the different groups. RESULTS Of 342 patients, 186 (54.4%) patients had one or more comorbidities, and 156 (45.6%) patients had no comorbidities. Of 186 patients with comorbidities, 160 (86%) patients were malnourished, and only 26 (14%) had normal nutritional status. Of 156 patients without comorbidities, 95 (61%) were malnourished, and 61 (39%) had normal nutritional status. The relative risk of developing malnutrition in patients with comorbidities was significantly high, compared with patients without comorbidities (risk ratio, 3.9; 95% confidence interval [CI], 2.3 to 6.6; P = .001). According to time-dependent multivariate Cox regression analysis, the hazard ratio of mortality was 3.6 (95% CI, 1.1 to 11.7; P = .03) in patients with normal nutrition with comorbidities; 2.9 (95% CI, 1.1 to 7.8; P = .03) in patients with malnutrition without comorbidities; and 6.6 (95% CI, 2.6 to 16.5; P = .001) in patients with both malnutrition and comorbidities. The risk ratio of mortality in patients with both malnutrition and comorbidities was 3.7 times higher than in patients with malnutrition without comorbidities. CONCLUSIONS Patients with comorbidities are at high risk of developing malnutrition. Comorbidities and malnutrition, alone or together, constitute independent predictors of survival in these patients. Patients with both malnutrition and comorbidities demonstrate the worst survival. Malnutrition and comorbidities seem to exert a confounding effect on the survival of CAPD patients.

Etiological diagnosis of granulomatous tubulointerstitial nephritis in the tropics

Background Granulomatous tubulointerstitial nephritis (GIN) is common due to infections, drugs or sarcoidosis. However, the cause is often difficult to establish and the studies are limited. We studied the etiology of GIN and compared the clinical and histological features and outcome in different etiologies at a tertiary care center in North India. Methods Renaö biopsies from GIN cases diagnosed from January 2004 to April 2014 were retrieved. Stain for acid fast bacilli was performed in all biopsies. Etiological diagnosis was based on clinical features, extra-renal manifestations, radiology, history of drug intake and demonstration of infective agent. Tissue PCR for tubercular DNA was performed in seven biopsies. Results Seventeen GIN patients [mean age 35 ± 15 years; males 11] were identified. Tuberculosis was the commonest etiology followed by idiopathic, sarcoidosis and fungal. Both tuberculosis and sarcoidosis patients presented with subnephrotic proteinuria and raised serum creatinine. Acid fast bacilli were demonstrated in 1/9 and necrosis was demonstrated in 3/9 granulomas in tuberculosis. Tissue PCR for tubercular DNA was positive in six TB patients and negative in one sarcoidosis patient. Patients responded well to appropriate therapy. Conclusion Etiological diagnosis of GIN is essential for timely and appropriate therapy. Tuberculosis is the commonest etiology (53%) in the tropics. Necrosis in granuloma, demonstration of acid fast bacilli, blood interferon gamma release assay and urine culture is not sensitive for the diagnosis of tuberculosis in GIN. Our findings suggest that tissue PCR for tuberculosis performed in an appropriate clinical setting is useful in the diagnostic evaluation of GIN.

Is basiliximab induction, a novel risk factor for new onset diabetes after transplantation for living donor renal allograft recipients?

It was found that, by affecting populations of T lymphocytes and regulatory T cells, basiliximab also indirectly affects pancreatic β‐cell function and glucose homeostasis.

Urinary Kidney injury molecule-1 can predict delayed graft function in living donor renal allograft recipients

Delayed graft function is an early complication leading to impaired creatinine clearance, urine formation and determinant of long term graft outcome. The aim of the present study was to determine the earliest predictive cut‐off value of uKIM‐1 level in patients with delayed graft function and acute tubular necrosis.

Chyluria: a mimicker of nephrotic syndrome.

BACKGROUND AND OBJECTIVE Chyluria can be confused with nephrotic syndrome when massive proteinuria is present on urine examination during evaluation of a milky/white urine. Our objective was to attempt to resolve diagnosis in the case of nephrotic range proteinuria when there is no clear evidence of a significant kidney lesion. DESIGN AND SETTING Retrospective review of the medical records of all patients referred the nephrology department at a single institution. PATIENTS AND METHODS We identified a subgroup of patients misdiagnosed with nephrotic syndrome and treated aggressively with immunosupression with no benefit and who were later diagnosed as having chyluria. RESULTS Twelve patients were identified (8 men, 4 women) with a median age of 34.5 years. Chyle was positive in the urine in eight while chyle was positive on oral ingestion of butterfat in another 4. Six had undergone kidney biopsy and were treated as having minimal change disease. Eight had massive proteinuria and a history of treatment with prednisone, but none of these patients had shown improvement in their clinical presentation. Two patients showed excellent results with diethylcarbamazine with angiotensin-converting enzyme inhibitors in while eight required betadine instillation in the fistulous connection with success in six. Surgical correction was successfully tried in two of these resistant cases. CONCLUSION In individuals with nephrotic range proteinuria with a normal or low lipid profile status along with normal serum albumin levels, urine color and nature, frequency, and checking the urine for chyle can help identify the large subgroup who unnecessarily have to undergo kidney biopsy and at times are treated with immunosuppression, which is not only life threatening but useless in these patients.

Effect of metabolic syndrome on clinical outcomes of non-diabetic peritoneal dialysis patients in India.

Metabolic syndrome (MS) is associated with higher mortality and morbidity in the general population. However, the effect of MS and its individual components on clinical outcomes in non‐diabetic peritoneal dialysis (PD) patients has not been widely studied in India. Our aim was to study the prevalence of MS in non‐diabetic PD patients who were on PD for at least 3 months and to analyze the influence of MS and its individual components on clinical outcomes of these patients on subsequent follow up.

FGF23 is associated with early post-transplant hypophosphataemia and normalizes faster than iPTH in living donor renal transplant recipients: a longitudinal follow-up study

Background We aimed to longitudinally analyse changes in the levels of serum fibroblast growth factor 23 (FGF23), intact parathyroid hormone (iPTH) and associated minerals in patients undergoing renal transplantation. Methods Sixty-three patients with end-stage renal disease (ESRD) who underwent living donor transplantation were recruited. Serum FGF23, iPTH, uric acid, inorganic phosphorous (iP), blood urea nitrogen and serum creatinine were measured pre-transplant and at 1 (M1), 3 (M3) and 12 months (M12) post-transplantation. Results FGF23 levels were decreased at M1, M3 and M12 by 93.81, 96.74 and 97.53%, respectively. iPTH levels were decreased by 67.95, 74.95 and 84.9%, respectively. The prevalence of hyperparathyroidism at M1, M3 and M12 post-transplantation was 63.5, 42.9 and 11.1%, respectively. FGF23 and iP levels remained above the normal range in 23 (36.5%) and 17 (27%) patients at M1, 10 (15.9%) and 5 (8%) at M3 and in none at M12 post-transplantation, respectively. A multivariate regression model revealed that, pre-transplant, iP was positively associated with iPTH (P = 0.016) but not with FGF 23; however, post-transplant, iP level was negatively associated with FGF23 (P < 0.001) but not with iPTH. Conclusions Post-transplant FGF23 levels settle faster than those of iPTH. However, 11% of patients continued to have hyperparathyroidism even after 12 months.

Contrast-induced acute kidney injury

Abstract Contrast-induced nephropathy (CIN) is described as a sudden deterioration of renal function i.e. an increase in serum creatinine (SCr) > 25% or an absolute rise of 0.5 mg/dL over a baseline in SCr within 48 hours of intravascular contrast administration in the absence of an alternative cause in absence of any other cause. The CIN has been reported as third most common cause of acute kidney injury in hospitalized patients. The exact mechanism of nephrotoxicity due to contrast agents is not yet clear yet it is presumed to be interplay renal vasoconstriction resulting in medullary hypoxemia and the direct cytotoxic effects of contrast agents on renal tubular cells. Diabetes, multiple myeloma, and advanced age are some of the modifiable factors while contrast volume, shock, hypotension, and congestive heart failure are a few non-modifiable risk factors for its occurance. Use of an imperfect marker of kidney function (SCr) may result in a false sense of safety, as only the ‘tip of the iceberg’ is being exposed by such measurements. Use of intravenous normal saline, sodium bicarbonate infusion and N-acetylcysteine are relatively cost-effective and safe, in reducing the risk of CIN, and may considered in patients undergoing procedures with intravascular contrast.